Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 566202639
Report Date: 08/19/2015 12:00:00 AM
Date Signed 08/19/2015 05:59:20 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME:WEISS FCC AKA ROBIN'S NESTFACILITY NUMBER:
566202639
ADMINISTRATOR:WEISS, ROBIN IRENEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(805) 388-0150
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY:14CENSUS: 10DATE:
08/19/2015
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
03:20 PM
MET WITH:Robin Weiss & Tristan ElizaldeTIME COMPLETED:
06:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Wu made an unannounced visit to this one story, 5 bedrooms, 2 baths corner house to conduct an Annual/Random inspection. Licensee and her assistant Tristan Elizalde were caring for 10 children (one of the child was licensee's grandchild), six children were under the age of two. Licensee had a U shape house with the front door facing one street, and two wings, one wing on the left (if you face the house from the street) was the garage that had two openings, one facing another street, the other opening facing the center court with a double glass doors. The garage could only be entered from outside of the house. The left wing was the child care room accessible through the double glass door, adjacent to the kitchen, the dinning room and main part of the house. there were sufficient toys and material inside the play room, and the center court had plenty of play structures over the concrete ground. The area was fenced with iron rod gate about 2-1/2 feet tall and enable the area as children's outdoor activity area. The kitchen and the bathroom children used were observed free of hazards. The back yard could be accessed through the sliding door from the kitchen/living room area, but it was only used for family members. Younger children napped in the portable cribs in some of the bedroom along the hall way (there were sun roof to provide light over the hall way), older children napped over mats in the family room adjacent to the living room. There was a child safety gate blocked the entrance between the child care room and the main portion of the house. The fire place in the family room was secured by a metal chain screen. There were no bodies of water observed at the premises. Licensee stated there were no guns or ammunition at home. Licensee participated in food program, but did not have children referred by CDR, nor did she have a foster child care license. Licensee had smoke detector and carbon monoxide installed on the wall and bedrooms, and one of them were tested and found in working condition today. Licensee conducted a fire/emergency drill on 2/15/2015. Licensee and her assistants Tristan Elizalde & Amanda Ross had CPR/First Aid certificates until 6/2016, but these were online training, and Licensing Department did not accept online training certificates; however, Licensee had certificate issued by California Department of Public Health as a Nurse Assistant, and the certificate was valid until 5/11/2016. LPA Wu discussed Incidental Medical Services (IMS) & PLAN with the licensee should she decide to take on the responsibility administering medication to children with special needs. Children's roster and files were reviewed.

The report would continue to LIC809-C & LIC809D..
SUPERVISOR'S NAME: Patricia S. GutierrezTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Ying Ying WuTELEPHONE: (805) 883-8244
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2015
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: WEISS FCC AKA ROBIN'S NEST
FACILITY NUMBER: 566202639
VISIT DATE: 08/19/2015
NARRATIVE
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Licensee's assistant Tristan Elizalde had been working at the facility for more than one year, but her clearance did not show up in the system, and she or Licensee were not able to present the proof of a Live Scan copy or a Transfer Request to LPA Wu during the visit.

Licensee's type 3A40BC fire extinguisher sitting on the kitchen counter appeared to be new; Licensee stated the fire marshal was here in 12/2014 to conduct their annual inspection, informed her to install current smoke detector and carbon monoxide, and that's when she obtained the fire extinguisher at Costco, but she was not able to provide the receipt for LPA Wu during the visit.

Licensee had one big and one small breed dogs that mostly stayed in the back yard, and Licensee was made aware the safety of children around animals.

Three type A & one type B deficiencies were cited today:

Criminal Background Clearance for Tristan Elizalde, $500 Civil Penalty was assessed today.

Staff Ratio & Capacity - Licensee and her assistant cared for 10 children, 6 of them were under the age of 2.

Operation of a Family Child Care Home: Fire Extinguisher - without a receipt.

Immunization Record - Licensee did not transfer children's immunization records into the blue cards as required by the Licensing Department.

A Type A deficiencies is being cited today. Licensee was provided with a copy of appeal rights. This report must be posted for 30 days. Licensee is to provide a copy of this report to each parent/legal guardian of every child for the next 12 months. Every parent/guardian must sign a LIC 9224 "Acknowledgment of Licensing Reports" and place a copy of this document in each child's file for the next 12 months.
SUPERVISOR'S NAME: Patricia S. GutierrezTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Ying Ying WuTELEPHONE: (805) 883-8244
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2015
LIC809 (FAS) - (06/04)
Page: 4 of 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: WEISS FCC AKA ROBIN'S NEST
FACILITY NUMBER: 566202639
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/19/2015
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/26/2015
Section Cited
102418 (g)
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Immunization. Licensee shall document and maintain each child’s immunizations as long as the child is enrolled.
Licensee stated she ran out of the blue card, and was not aware that she needed to transfer the immunization record parents provided to the blue card.
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Licensee was provided a packet and form to make blue card and she would complete these immunization records by 8/26/2015 and inform LPA Wu.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Patricia S. GutierrezTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Ying Ying WuTELEPHONE: (805) 883-8244
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2015
LIC809 (FAS) - (06/04)
Page: 3 of 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: WEISS FCC AKA ROBIN'S NEST
FACILITY NUMBER: 566202639
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/19/2015
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/20/2015
Section Cited
102370 (d)(1)
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Criminal Record Clearance. All individuals subject to a criminal record review as specified in Section 1596.871 prior to working, residing or volunteering in a licensed home, shall obtain a California clearance or a criminal record exemption as required by the Department.
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Licensee would have Tristan submit her Live Scan immediately before she could come back to work at the facility.

A $500 civil penalty was assessed today.
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Licensee's 21 year old assistant Tristan Elizalde who worked there for more than one year did not obtain a clearance prior to working at the facility.
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Type A
08/20/2015
Section Cited
102416.5 (a)
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Staffing Ratio and Capacity. The capacity specified on the license shall be the maximum number of children for whom care can be provided.

Licensee and her assistant Tristan Elizalde were caring for 10 children, six of them were under the age of 2.
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Licensee stated she would inform the parents to limit her children in care and would submit a weekly schedule to show that the children in care were not over the capacity she was licensed for.
Type A
08/20/2015
Section Cited
102417 (g)(1)
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Fire extinguishers and smoke detectors shall meet State Fire Marshal standards.

Licensee had one type 3A40BC fire extinguisher sitting on the kitchen counter appeared to be new. Licensee stated it was purchased at Costco in 12/2014 when fire marshal was here, but couldn't find the receipt
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Licensee stated she would go to the Costco to obtain a receipt of the purchase and submit it to LPA Wu by tomorrow.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Patricia S. GutierrezTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Ying Ying WuTELEPHONE: (805) 883-8244
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2015
LIC809 (FAS) - (06/04)
Page: 2 of 4